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.:,�, IZTORING WELL INSTALLATION REPOn",, <br /> Date: �� G moi' CONSTRUCTION <br /> Premise Address: 5��'W ` J-7 4- Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) . <br /> Inspector: 1a17-1Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> / /� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ` <br /> Driller: 1714 casing <br /> height <br /> Consultant <br /> -Q%r <br /> Geologist , yl�p � �� "' <br /> AE&E-GROUND C-GMTY480X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) �__ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> _ m <br /> = o <br /> slottad w <br /> SAMPLING .— <br /> saclon <br /> Holding Temperature ¢1191 P?o <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> Storage Method MATE RIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage Location Blank ft. Screen ----ft <br /> - <br /> Storage <br /> size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />